Thursday, May 24, 2012

Arua Rural Rotation (13 May - 23 May)

I spent last weekend in Kampala since on Sunday, Renee and I had to leave for our week long rural rotation in Arua - a town in northwestern Uganda near the Congo border. The weekend was pretty quiet. Renee and I went out on Friday night with our housemate Sarah and Lucy - the wonderful woman who runs Edge House. The place we went to was packed and everyone was dancing. Feeling tired from our week, Renee, Sarah, and I were the first to leave the dance party and head home. Saturday morning was lazy as well. I enjoyed sleeping in and relaxing at the Edge House and Makerere Guest House, reading and writing emails. That night we went out to watch football (soccer) at a local pub. We didn't get home early enough for the time we had to get up Sunday morning so the 6am alarm I set was quite unwelcome. Renee and I had a ride coming at 630 to bring us to the bus booking office to book our bus tickets and catch the 730 bus to Arua. It was a bit of an adventure to get our tickets and get on the bus. We were at the booking office by 645 but no one who worked there was around. We sat and waited. The bus to Arua arrived before any of the office workers did. Finally around 710, an office worker arrived and Renee got in line to buy our tickets while I watched our luggage. While she was not making any progress in the line, a man starting yelling "15 minutes until the bus leaves. 15 minutes!" then it was "10 minutes!" then "5 minutes!" Finally Renee made it to the front of the line and as the man was making the final call for bus boarding, we got our tickets, gave our luggage to the guy loading luggage under the bus and took our seats at the back.

The journey was pretty uneventful albeit long and not the most comfortable. It is between 7-8 hours from Kampala to Arua and for a bus ride that long, I definitely do not recommend sitting in the back of the bus. I was tired enough to sleep but too uncomfortable to actually get any meaningful sleep on the road. Every time I seemed to fall asleep, the bus would go over a pothole or one of the many speed bumps and Renee and I would be airborne - not so conducive to sleeping.

We made it to Arua a little before 3 in the afternoon and Renee called Dr. Alex, our supervising doctor for our time in Arua. We waited at the bus station for about 20-30 minutes for him to pick us up and take us to our lodging. Our home for the weeks is pretty nice. We are just outside Arua town adjacent to a golf course. We have a clean and comfortable room although there is only electricity for about 5-6 hours a day and although the shower has hot water, the shower head doesn't exactly work so I have to shower underneath the faucet. The restaurant has good food and we get breakfast so I really have no complaints. And it's cheaper than staying at the Edge House for a week. After getting settled and relaxing for a while on the porch outside our room, we ordered dinner. As soon as we ordered, Dr. Alex called us and said he wanted to take us out somewhere. We paused our dinner order and when we arrived, we discovered he was taking us to the hospital for a quick look. Apparently there was some trauma that was coming in and he was called in. It must not have been much of an emergency if he had time to pick us up before going and when we got there, there were no patients. The "emergency" never came in. We left the hospital and instead of going back to our lodging, Dr. Alex took us to his house where we met his mother and a friend of his. We hung out there and watched television - neither Renee nor I had any idea what was going on. Plus we were getting increasingly hungry and tired. After about a half hour, we got back in the car, this time with Dr. Alex's mother and friend and headed further out of town where we picked up some more people then went to the District Hospital to visit a patient who is somehow connected to Dr. Alex personally. It was interesting to see, but not on a Sunday night and after 8 hours on an uncomfortable bus. The best part about the hospital was when we saw a few cows wandering around on the grounds. After an hour, we finally were brought back to our lodging and had our dinner - fish and chips (French Fries). The fish was literally a whole fish, head, tail and all and Renee had to teach me how to eat it. It was really tasty and definitely welcome after not having eaten much all day. We went to bed exhausted and ready to start a new day at the hospital.

Monday morning we got up and had breakfast at the hotel. We were supposed to be picked up at 830 but didn't end up getting picked up until nearly 9. We were taken to Arua Regional Referral Hospital to the casualty ward. The hospital had a long queue of patients already waiting and the medical and surgical casualty were full. Renee and I met Dr. Alex and got to work seeing patients. It was nice that we had the autonomy to see patients on our own but then staffed our patients with Dr. Alex. It was nice to have the supervision and feedback. I saw a wide variety of pathology - two cases of malaria, several fractures, a late presentation of congestive heart failure due to mitral valve incompetence, a patient with a 16cm spleen due to liver failure and portal hypertension. It was great to get some exposure to things that I either don't see often if at all at home and to see diseases late in their natural course. At the same time, it is sad that those things exist here and although it is great for my medical education, it makes me sad that people do not have equal access to healthcare resources everywhere. The entire country is pretty resource poor so everyone is equal in the lack of resources unlike at home where we have the resources, but unequal access. After all that I have seen this year and working with so many international medical students who come from countries with healthcare systems that equally take care of everyone, I am more convinced than ever that healthcare should be a human right and everyone should have equal access.

I think Renee and I have gotten quite used to Ugandan time and both of us will have to switch back quickly when we get back home. This morning we were supposed to go to the HIV/TB ward for ward rounds which we were told started at 8:00am. We had plans to try and leave between 7:40 and 7:45 to walk to the hospital. We didn't leave our room until about 7:35 and then when we went to have breakfast, the breakfast wasn't ready. We ended up not leaving until a quarter after 8 and made it to the hospital by 8:30. At home, this would certainly not be acceptable. Here, the doctors had not even arrived on the ward yet. Arriving a half an hour late, we still managed to have time to get a complete tour of the ward with an introduction to all the patients before the ward rounds started. It was interesting to see these patients of which we rarely if ever see at home. They are some of the sickest looking patients I have seen so far during my time in Uganda. The worst part was how young most of them were. It's sad to see people my age or younger wasted away from the AIDS and riddled with TB - pulmonary, meningitis, effusions, was all there. The worst patient I saw was on re-treatment for TB after having stopped taking his medicines the first time around. Unfortunately for this patient, he had a severe drug reaction likely to one of the new TB medications causing him to develop horrible bleeding ulcers all over his mouth and gums and his skin to start sloughing off of his feet and legs. This drug reaction can be life threatening and so all TB medications were stopped in an effort to treat his drug reaction. After our morning on these ward rounds, Renee and I decided it was time for lunch before heading back to the casualty ward for the afternoon. When we arrived on the casualty ward, there were no consultants present. There was one nurse who was about to leave for her lunch break and a few nursing students around and that was it. The nurse told us that there was one very sick patient that she thought might have TB and told us to put on masks before we went to see him. Renee and I decided that if we were left alone, we would see patients together because two medical students, even though still not equivalent to one doctor, is better than just one medical student. The moment I saw this patient, I was reminded of the ward where we had spent our morning - he was emaciated, clearly sick, with a cup that was slowly filling with the sputum he was coughing out from his lungs. His BP was low and his heart rate was high so we decided to give him fluid resuscitation. There were no nurses or nursing students around at this point and so I placed the IV line myself. We finished taking his history and doing his exam then went to work on the paperwork to admit him and get him a chest xray, a PPD skin test, and a rapid HIV test. After this first patient, the patients continued to keep on coming. Together Renee and I managed two patients with hypoglycemia, a malaria patient, an acute abdomen, an gangrenous toe with cellulitis, and finally two nursing students who asked for us to consult for them since they were not feeling well. There may have been more, but when things get busy in the casualty ward, I don't always have time to record each patient that I see. The problem also is that the nursing students don't always understand what Renee and I ask them to do. For our two hypoglycemic patients, we gave them both dextrose to treat it. According to my Emergency Medicine Manual, you are to give a 50mL bolus of 50% dextrose then recheck the sugar, and if it's still low, repeat the bolus. The only bags of 50% dextrose we had were 100mL. I drew a line through the middle of the bag and asked the students (who had all appeared when previously when the likely TB/HIV patient was there had disappeared), to watch and stop the drip when the fluid level reached the line. The next time I glanced at those patients, both of them had received the entire 100mL of dextrose. Of course as a result, they went from being hypoglycemic to a not insignificant level of hyperglycemia. At least the body is able to compensate for a transient hyperglycemia better than the hypoglycemia so hopefully there isn't any long term iatrogenic sequelae. The best part about these episodes with both patients is that Renee and I are pretty sure we figured out the underlying cause for the hypoglycemia in the first place - one was probably a medication side effect in combination with not having eaten or drank anything all morning then going out to do physical therapy. The other one most likely has a gastric ulcer - she had not eaten or drank all day and when I asked why she said that for the past month she had stomach pain every time she ate. She also drinks a lot of coffee and was recently on a medication for heart palpitations. This may be the one and only time that I see the initial presentation of a gastric ulcer as a hypoglycemic episode.

After finishing in casualty, Renee and I were invited to dinner at the home of a Minnesota couple (United Methodists from New Ulm) working for the Peace Corps here in Arua. We had a delicious home cooked meal and a delightful time chatting and getting to know this husband and wife pair who have three children all around our ages and decided to join the Peace Corps because "we aren't dead yet." It was nice to be with people having a shared experience of being asked to do things beyond our training and comfort level. It was great to make some new friends. Feeling full after dinner and eating a few local mangoes, we headed back to the hotel very happy and content with our day. We may be extending our stay in Arua for a few days...

After two long and tiring days of working in the hospital, Renee and I decided that Wednesday would be a short day if it was nice and we would leave the hospital around lunch and head to the one and only pool in Arua for the afternoon. The day was beautiful - perfect for relaxing by the pool. At the hospital that morning we went to the pediatric ward to join the pediatric ward rounds. The doctor was later than we were in arriving and he was alone doing the ward rounds that morning. In one room alone, there were 25 patients. In the first hour, we only got through two of them and this was not because there was a lot of teaching happening, it was because of the disorganization of the files and the fact that many of the patients were new or were supposed to have various testing done and there was a search for results or a search in the record to find out why exactly the child was admitted. The consultant had a lot of work to be done and not a lot of time for teaching. After a few hours, Renee and I had figured out that we were not going to get much out of pediatric ward rounds and decided it would be better for us to leave and relax and recharge for the rest of the week. The pool in Arua is fairly small - not great for a pool workout but I attempted to get at least a long warm up in - but it is quiet and very relaxing and the adjacent restaurant had delicious food. Despite our repeat application of sunscreen, we both left the pool burnt after spending more than 6 hours of our afternoon there. I was able to finish my book (Cutting for Stone - great book!) and both of us left feeling much more refreshed.

Thursday we were back at work. We had planned to attend the Under 5 Clinic that morning. On our way there, the Peace Corps nurse from Minnesota caught us and took us around the maternity ward. The nice thing about this maternity ward compared to Mulago is that there are actually curtains between the women so they are not just lying out in the open laboring in front of 20-30 other women. When we arrived at the Under 5 Clinic, there was no doctor there yet and soon we were asked by the Peace Corps nurse to come see a child in casualty who had been referred to Arua from a nearby hospital for severe malaria and anemia and was in bad respiratory distress. The other hospital had told the family that there was nothing that could be done to save the child, but we were asked to take a look and give our opinion. This is definitely not a job for medical students but as again there were no consultants to be found in casualty, Renee and I reluctantly took charge. We put the child on oxygen (miraculously, they had this available in casualty) and started trying to start an IV line and also work to get the child admitted and under the care of the pediatrician who happened to be present on the pediatric ward.

After we sent the child straight away to the pediatric ward, we had two unconscious patients. One I'm pretty sure has tetanus (we were also considering cerebral malaria and bacterial meningitis). She was completely rigid all over including her jaw. Apparently one month ago she was given tetanus toxoid (we couldn't get more history than that) and I'm thinking that as a result of whatever happened at that time, she ended up developing tetanus. The other unconscious patient was in respiratory distress. She had delivered a stillborn baby via cesarean section 5 months ago and had had abdominal pain since that time. We didn't come up with a diagnosis for her (my top concern was a pulmonary embolism) and so we admitted her to the ward. We had a couple of really sick kids with malaria and one with measles. I saw a diabetic patient who I'm pretty sure was in renal failure with a huge amount of fluid retained everywhere - lungs, abdomen, legs. There was one other unconscious adult - Renee and I diagnosed malaria again since it seems that is what everyone had here if they have a fever and some other vague symptom. We saw a patient who was oozing pus out his belly button. His abdomen was tense and tender and he had an abscess in the left lower quadrant. He also had a chronic cough with sputum production and was completely emaciated. He smelled like TB/HIV (literally - it has a smell) and so we admitted him and I'm pretty sure he has HIV and TB and who knows what that abscess is - probably TB. I started a few IV lines including one in a child.

There was one patient that really got to me today that I was concerned about and would have felt responsible had something bad happened to her. It was a young woman in her early 20s who that morning had witnessed her father die in a motor vehicle accident. She was hyperventilating in respiratory distress. She herself was not involved in the accident. Her family was really concerned about her - understandably although we could find nothing physically wrong with her. Renee and I were both pretty sure that she was in a state of mental shock had an acute stress disorder at that moment which was why she was in the state she was in. At the same time she was there, we had several other really sick patients and so she just wasn't a top priority after we ruled out everything serious. She would quiet down for a while and then all of a sudden scream and start hyperventilating again. Apparently she had been seen by someone while Renee and I were out for lunch and had been given "an injection" of something. No one there knew what she had been injected with and there was no note. I was guessing that she had been given diazepam but I didn't know. I asked all the nurses and the clinical officer I found in clinic but none of them had seen this patient and there were no notes or records anywhere for her. We had given her a bag to breathe into but that was also not helping. I decided to give diazepam thinking that the vial only contained 5mg and according to my Medscape reference, you can give 10mg in one dose. So I filled the syringe and quickly checked the vial - diazepam 5mg/mL - and it didn't register until after I gave it to her and she quieted within a minute that the vial contained 2mL - 10mg of diazepam, not 5mg. Again, this would be okay except for the fact that I wasn't sure what "injection" she had been given earlier and if it was diazepam, I had no idea how much had been given. So I was terrified that I would put in her in respiratory arrest and we don't have a ventilator (let alone an ICU) and if she died from respiratory arrest because I OD'd her on diazepam, it would have been all my fault. We had decided to admit her to the psych ward and thankfully by the time she was headed there, she was awake and breathing okay and no longer hyperventilating. That was the most terrified I have been yet for sure in Uganda (it even surpasses being left alone in the surgical casualty at Mulago). It also made me question if what I am doing here is really helping the patients. I wonder if I am actually making a difference for anyone...

The alarm went off Friday morning and as the week has gone on, it has become more and more difficult to get up when the alarm sounds. I laid in bed for an extra 15 minutes before I could get the energy to move. We decided to try and avoid the casualty ward again today and since yesterday was so intense, thought that maybe a half day with the afternoon spent at the pool (in the shade this time) if it was nice outside would be a good idea. It was another beautiful day as we walked to the hospital. When we arrived, we found that again there were no doctors in the Under 5 Clinic so we thought we would try and make our own ward rounds on the patients we had admitted from the day before. If you can imagine, it was really difficult to find our patients. Not only are the wards themselves all in separate buildings and unlabeled, but there is also not often a doctor present or anyone who knows the patients that are on the wards. Plus it didn't help that we didn't have any of the patient names written down - just the diagnoses we had contemplated and the ward we had sent them to. We did find a few of our patients - the woman we thought had tetanus/cerebral malaria/meningitis was actually conscious although she was still rigid and her jaw was still clamped shut. After making our rounds, we decided to see what was happening in the minor operating theater. There were a few procedures that morning that we observed. We saw drainage of a foot abscess, a circumcision on a 1 year-old child, removal of an inguinal lipoma, evacuation of a hematoma, and suturing of a laceration secondary to an assault with a knife. It was pretty interesting although sterile technique here definitely doesn't match the sterile technique either Renee or I was taught at home. The worst of the procedures to watch was the circumcision. There is a big campaign to get men circumcised since research has shown that it can reduce the likelihood of HIV transmission. Unfortunately, most of these circumcisions are done well after birth at an age when the boys or men can remember it happening. This one-year old was supposed to have his circumcision under general anesthesia but because his parents had fed him an hour before, he would have to wait 6 hours for the procedure. At home, I think they would have waited and done it later under general, but here, they decided to just do with local anesthesia and no sedation. They strapped the child down to the table with dad holding down his arms and chest and mom holding down his feet. It was borderline barbaric to watch. The child screamed throughout the procedure and for a while afterwards. Once all the procedures of the morning were done and there were no more patients waiting, Renee and I decided it was a good time to call it a day and head to the pool. We had a beautiful day and I was able to get in a short swim and do some reading and take a nap. It was very relaxing. We are both looking forward to sleeping in this weekend and resting up for our final few days in Arua next week.

The weekend in Arua was pretty quiet. Renee and I enjoyed sleeping in. Saturday was rainy but we managed to make it to the market in between the rains. The market is huge and busy and easy to get lost in. There are a lot of fabrics, clothing (new and used), toiletries, name it, it's probably in the market somewhere. The adjacent food market is also crowded with vendors selling a whole assortment of fruits, vegetables, beans, bread, grains, meats, and the delicacy fried flying ants. The rest of the day was pretty quiet. We read and lounged and then headed to the Indian Restaurant for dinner. After a delicious meal ending in tea, we headed back to the hotel to watch the Premier League championship match. The restaurant was crowded with mostly fans for Chelsea. It was an exciting football match and we went to bed quite late afterwards. Sunday morning we slept in a little then headed to the pool for some lounge time. In the afternoon we went to a dinner party hosted by some of the peace corps volunteers stationed in the West Nile region, including the couple we had dinner with earlier in the week. It was a great day and a very relaxing way to head into our final few days in Arua.

Monday we planned to go to the operation theater but they only operate on Tuesdays, Thursdays, and Fridays in the main theater so we went back to the casualty ward. Dr. Alex was back today after his nearly week long trip to Kampala so there were consultants present in the ED. This seemed to make everything a bit more chaotic as they tried to shuffle patients in and out as fast as possible. Instead of being able to evaluate a patient and consider the diagnoses and management plan, Renee and I mostly ended up just being scribes for the history and physical exam. There was not as much learning because there was not much teaching and we weren't given the time to really consider what we thought might be happening with the patients. Regardless, we saw a variety of pathology including a man with elephantiasis, a woman with a cervical and uterine prolapse, a facial tumor, a throat tumor, TB, infected wounds, and some lacerations that we each got to practice suturing. I sutured my first lip laceration which was good experience. All in all the day was okay but the best part came after we returned from the hospital. During lunch, Renee and I reserved our bus tickets for Wednesday to head back to Kampala. While on our way back from the bus office, we stopped by a sports store and bought a football (soccer ball), a pump, and I got myself a Ugandan Nationals shirt. The football we had played with back at Edge House belonged to some British students who have since left. Renee and I want to start playing again when we get back to Kampala so we bought a ball. We decided to try it out this afternoon and our kicking the ball around was interrupted by a group of young boys heading home after school. They joined us in playing a game where we all stood in a circle and one person was in the middle. The ball was passed around the circle until the person in the middle intercepted it and then whoever lost the ball was the new person in the middle. It was a blast and turned our day from kind of mediocre to really fun. Now we are relaxing again in the evening waiting for a our final day on our rural rotation.

We spent our final day in Arua in the major operating theater. Before going to the theater, Renee and I decided to take pictures of the hospital. Our photo taking continued as we dressed in the very non-matching scrub uniforms that they had us wear for our time in the OT. The surgeons had a variety of operations scheduled. There are two theaters but in general only one is used and the other is reserved for emergency cesarean sections. The surgeons do a bit of everything - general surgery, orthopedics, and ob/gyn surgery. I was impressed by their speed of operating and the room turnover speed as well. They got through the morning's cases very quickly. We saw a variety of operations including two hernia repairs, a cesarean, a thyroidectomy, an appendectomy, and debridement for osteomyelitis. There were a lot of things that were done differently in Arua compared to at home. Like in Haiti, there were a lot of ants and flies in the OT and during the osteomyelitis case, one fly landed on several of the surgical instruments and the surgeon's hand and the surgery continued without spraying the instruments or the surgeon changing the best of circumstances, osteomyelitis is difficult to cure, but here it seems like it may be nearly impossible. This operation seemed like a last effort to get rid of the infection before this 6 year old boy will need to have his leg amputated. Both hernia repairs (epigastric and femoral) were done with local anesthesia only. The surgeons injected lidocaine at the site of the incision and down into the tissues and when the patient cried in pain, they would inject some more. After the surgeries were done, the patient was asked to get up off the table themselves and walk out of the OT. They did use general anesthesia for the thyroidectomy and appendectomy but general anesthesia here is with ether gas and there are no monitoring devices for the anesthesiologist to use to measure heart rate, blood pressure, or oxygen saturation. These measurements were not even taken manually during the surgery. Perhaps the lack of monitoring is part of the reason why they use local anesthesia instead of general for as many cases as possible. The anesthesiologist also did not listen to the chest after intubating the patient either - at least the surgeons operate pretty quickly in the event that the tube was not in the right position... The cesarean was an interesting case. The mother had 4 previous cesareans and this pregnancy was complicated with high blood pressure and placenta previa. Because of all these factors, the baby was delivered at 31 weeks - pretty early especially in a setting where there is no NICU. The baby was only about 3lbs but had a vigorous cry after delivery and seemed to be doing okay. Being premature in a place where so many children die before the age of 5 due to malnutrition, malaria, diarrhea, or respiratory illnesses is really a disadvantage. It's hard to be hopeful in a case like this. The thing that I was most happy about was that the mother consented to a tubal ligation with her cesarean - with a 5th uterine scar, her chances of a uterine rupture if she were to become pregnant again would be quite high.

After the OT, Renee and I had some lunch then went back to the casualty ward one last time. We saw a couple of malaria patients and got them admitted then took some last photos with the staff of Arua Regional Referral Hospital. After we said our goodbyes there, we made one last stop at the home of Marcy and Tom (the peace corps volunteers from Minnesota). Although it was sad to say goodbye, we were both excited to get back to Kampala. Our bus trip Wednesday morning was uneventful except for when we got to the one bridge traversing the Nile that connects the West Nile region to the rest of Uganda. There is a security checkpoint here as a result of the LRA and Joseph Kony and everyone has to get off the bus, show their ID and have their bags searched. It was nice to get off the bus for a few minutes in the middle of our 8 hour bus ride. The funnies part was the sign that pointed out an animal checkpoint. I'm not really sure what they search the animals for, but apparently even animals are not exempt from the security checkpoint. We arrived safely back in Kampala and were able to celebrate with our friends Sarah and Ruth who were leaving that night and the following day, respectively. It is always hard to say goodbye especially to Ruth who had been with us since the beginning of our time in Uganda. It is the friends we have made while sharing these intense experiences that help to keep us sane and to take a step back and still be able to enjoy everyday.

Location:Arua, Uganda

Monday, May 21, 2012

2 Weeks in Surgical Casualty

I spent the past two weeks at Mulago Hospital in the surgical side of the casualty ward. This is similar to the emergency department at home. It is separated into a medical side and a surgical side and is staffed by medicine doctors and surgeons, respectively. I had heard this was a great place to get some practical experience especially with suturing up lacerations. At first I was surprised at how small the ward was. It is made up of several rooms - one is the main treatment room where most of the patients are seen. There are only 4 beds in this room that is divided by a half wall. Then there is a room for ultrasound, a room for xray, a resuscitation room, a plaster room (for orthopedic cases), and an emergency operating theatre. Most of my time on this service I spent in the main treatment room seeing patients.

The casualty ward is a busy place - on some days around 500-600 patients might be seen. The "slower" days average about 300 patients in one day. Despite the small amount of space in the main treatment room, there are a lot of "staff" people crowded in there and unfortunately not many of them are consultant physicians. During my two weeks, I was the only international student on the ward except for one day when my roommate Nicole joined me. There were several paramedical students and nursing students who also often lacked supervision. I often found myself not only in a position where I was without supervision, but I was also the supervision for the paramedical and nursing students. As I had the most knowledge and experience of us students, I was the senior. As a medical student, that is a very terrifying and humbling position to be in. I am very aware of what I don't know and when I need help and to not have anyone to ask when in that position is a horrible feeling. I am getting ahead of myself...

My first day on the ward was quite atypical. It was quiet. I was disappointed because I had heard such great things, and my first day I didn't end up being able to do much. I learned how the paperwork was filled out for patients and was able to suture up one patient's laceration, but that was about it. The next couple of days picked up and soon I was seeing and managing a lot of patients on my own. During this time, there was always at least an intern present for me to ask questions and to have check over my assessment and plan. All this changed on Thursday during my first week. The morning was a typical morning - the usual variety of trauma (mostly motor vehicle accidents), acute abdomens, back pain, swallowed foreign bodies, abscesses - I had lunch and then went back for the afternoon. When I arrived, the only staff present was the intern. There were not many patients in the emergency department and I got started on a new one that had come in. Soon after, a child came in with a femur fracture from a boda boda (motorcycle taxi) accident. The intern glanced at the patient and while I was still in the middle of evaluating the patient I had started on, he said "I haven't had lunch yet. You are okay to handle this, right?" Before I had a chance to answer, he left and I was alone with a couple of paramedical and nursing students. No nurses, no consultants. I was the most senior person there and I was in charge. I finished up what I was doing and went to see the femur fracture child. As I started my evaluation of him, two more trauma patients came in - the father of the child with the femur fracture who also had injuries from the accident and a patient with head trauma, several lacerations on his face and scalp and bleeding from his ear and nose. I was in way over my head and I knew that and was completely uncomfortable. Morally, I couldn't leave. Even though I was being forced to manage things by myself without supervision, I felt a responsibility to be there for the patients and try to do what I could to make sure that no one died. That was my only goal during that 1-2 hours I was alone - to make sure no one died. The paramedical students and nursing students wanted to help, but unfortunately they had so little experience that they needed me to explicitly explain what I needed them to do. It was terrifying having that responsibility. Somehow I managed and no one died and finally after being left alone in charge for 1-2 hours, the intern and one consultant returned. I finished up with the patients that had come in and talked with the consultants about them. It was nearly 5 and since that is when the international office closes and because I was exhausted from the afternoon, I left. The worst part about it is that even though I told both the consultant and the assistant to the international coordinator that I was left alone in charge of the emergency ward, the only response I got was, "Well, that's great for your learning." No. No it is not great for my learning to basically be experimenting on patients. I did what I thought to do and yes, no one died and I think I probably did the right things for these patients, but I should not have been left without supervision. I do not have enough training and these patients deserve better. They deserve to have trained professionals managing their emergencies and not an international medical student on her fourth day on the emergency ward.

This is one of those kind of days that makes me really grateful for the friends that I have and the support network that I have developed while in Uganda. I told my housemates about what happened, and they were so supportive and reassuring and helped me wind down after such an intense experience so that I could face the next day.

On Friday, I made sure to bring my Emergency Medicine Manual in my pocket to the emergency ward. If I wasn't going to have supervision, then at least I would have a text to consult so I had some kind of a teacher. I was very glad that I brought that book and for the rest of my time in emergency, it was my closest friend. Friday morning when I arrived, there were no consultants in the emergency department again. Apparently they were all at a meeting. I walked into a room with a few paramedical and nursing students and three bloody messes. The students were focusing all their time on the least critical of the patients - they saw that patient as an opportunity to learn how to suture. As they approached me to ask if I could supervise them, I asked if they had looked at any of the other patients. They had not. I told them that before I could supervise suturing, I needed to assess and triage the other patients that were there. The patient they were focusing on was stable - no bleeding, okay vitals, although he had amnesia for the event that lead to his coming to the hospital - concerning. The other two were in worse shape. One had several lacerations on his face and scalp and had lost consciousness after he had been in a motor vehicle accident. He had bleeding from his nose and ear and a huge hematoma forming underneath his scalp. The other was the most concerning of all. He had a laceration on his head and an open wound on his ankle and was actively vomiting - a sign of increasing intracranial pressure. Thankfully I was not alone for long before the consultants returned from their meeting and I could relax a little and just focus on one patient instead of three.

Mulago is the National Referral Hospital and so cases from all over the country are brought here when they have surpassed the expertise or resources of the smaller district and regional hospitals. It also is the regional hospital for Kampala and so a wide variety of pathology is seen on the wards. Although the surgical casualty wards tends to see a lot of trauma patients, a fair number of other interesting things walk through the door as well. I saw one woman who had a suspected meningioma for the past ten years. One entire side of her face was puffed out from the tumor. Because they don't have any treatment available for her, her tumor just keeps growing. It seems we get a lot of late presentations of cancers. The patients don't seem to come in until something has really advanced and so we see some huge masses or patients who are wasted away from throat cancers who haven't been able to eat for months. We also see a lot of bread and butter emergency room problems as well - I saw many young children who had swallowed coins or batteries or some other object and acute abdomens. The trauma patients often seem to involve boda boda accidents. The worst of these involved three people on the same boda - the driver, an older woman, and her grandchild. All three of the boda riders had right sided mid shaft femur fractures. The older woman also had a right sided humerus fracture. Both the driver and the grandchild had open fractures - the driver's fracture had a huge piece of skin missing and a large hematoma had already formed above the fracture site. All of the fractures are set in the casualty ward before they are moved to the wards. Depending on who is working in the plaster (ortho) room, the patients get varying amounts of analgesic relief before manipulation of their fractures. One orthopedist was really great and made sure all patients had morphine on board before reducing and setting the fractures. Others will do the manipulation when the patient has only received diclofenac (an NSAID like ibuprofen) - you know when these patients are being reduced because their screams reverberate throughout the entire third floor of Mulago.

It isn't just with ortho manipulations that pain management often seems a bit lacking. I saw one woman with a peritonsillar abscess. The casualty physician stuck a scalpel blade on the end of a clamp and was poking at the abscess at the back of her throat to try and drain it. I have seen a lot of kids with abscesses. It doesn't seem to matter how old the child is or where the abscess is located, they are all drained in the emergency ward without any sedation and sometimes not even local anesthesia. It's also hard to watch the parents have to pin their children down in order to keep them still so that their abscesses can be drained.

The other difficult thing about having so much responsibility for making treatment and management decisions is that I am not really sure what resources are available. Many of my boda accident patients, I have wanted to get a head CT on because I was concerned about intracranial hemorrhages. Of the several that I ordered, I don't really know how many of them were actually done. I found out that there is only one neurosurgeon at Mulago Hospital so even if there was a CT done and it showed a hemorrhage, there isn't a guarantee that a patient would be able to have burr holes drilled in the event of increased intracranial pressure anyway.

The lack of readily available CT is also a problem for other patients. I spent one morning/afternoon in the resuscitation room where a man was brought in. His initial complaint was an acute abdomen and he soon became non-responsive. Initially the physicians taking care of him thought that he had a ruptured spleen - there was some story about an accident/fall and after an ultrasound, there was free fluid seen in the peritoneum and so splenic rupture was suspected. We started rapid resuscitation measures but his blood pressure just wouldn't pick up. He was taken to surgery (relatively quickly - maybe an hour or two after being in the resuscitation room) for an emergency laparotomy. When the abdomen was opened up, the surgeons were surprised to find not blood but intestinal fluid filling up the abdominal cavity. The patient had a perforated ulcer, not a ruptured spleen and was likely in septic, not hemorrhagic, shock. Looking at the records after this discovery, we saw that this accident had happened over a week ago. The patient survived the surgery but died later that night. Had the diagnoses been known (better imaging would have helped improve the odds of making a correct diagnosis), the patient would have not had surgery immediately, but would have been treated more conservatively with antibiotics and measures to increase his blood pressure before being taken to surgery to repair the hole in his stomach.

Despite the challenges and difficulties of working in casualty, I have become even more sure that emergency medicine is the right field for me. I enjoy the fast pace and the variety of patients that I see. I enjoy the hands on aspect - I have lost count of the number of patients I have sutured. I also think it is a great opportunity to do teaching to improve the care that people get when they come to the casualty ward and therefore improve their outcomes. It's the kind of teaching that you can do to enable the people already here to help make the hospitals less dependent on foreign aid.

Location:Kampala, Uganda

Sunday, May 13, 2012

The First 3 Weeks - Outside Mulago

Uganda so far has been the best overall experience. As you probably gathered from my blog about my Ob/Gyn rotation, I am getting incredible hospital experience both in knowledge and practical skills. I also have had a great time with all the wonderful people I met while living here and have had a blast hanging out in Kampala as well as doing some traveling in Uganda.

The Edge House where I live is a busy place. It is usually always full and it doesn't take long after one person leaves before a new one arrives to take their place. Most people tend to stay for anywhere from 4-6 weeks so I will for sure completely switch groups of people in the house once if not twice. The best part is that a few days after I arrived, a girl from the Netherlands (Renee) came and she will be here for the same amount of time that I am. We seem to get along well personality wise and I am excited for the adventures we will have while in Uganda. As I write this, there are 6 people that have already left the house (not including people I met that stayed elsewhere and have left) and another 7+ that will leave at the end of this week. I have had an amazing time with the people I have met the first quarter of my trip and anticipate that each group that comes next will be just as great.

Edge House is definitely the best house. We hang out a lot together and the people that run it - Freddie, Nassa, and Lucy - are fantastic. They even do our dishes for us :) At least a few times a week we go out to dinner together and whenever anyone leaves, the whole house is really good about going out together for a final farewell dinner. Someone always has an idea of a new place to try so I have had Ugandan, Indian, Chinese, Italian, Mexican, and "continental" cuisine. If someone hears about something cool happening on a night in Kampala, they will write a note on a white board that we have and usually there will be a group of people that will go. We went to the contemporary national ballet at the National Theater one night followed by a poetry and hip hop cultural night. I've watched soccer matches on a giant screen at a bar/restaurant called Mish Mash. I've had a massage at the nearby country club and spent two afternoons by the pool. Just last night I went to the Dutch Queen's Party - who knew there were so many Dutch people living in Uganda! I also went to a house party of one of the residents from the UK that I met on rotation with 8 of my housemates. The house party was the coolest house party I think I have ever been to - they had a DJ and a rolex man. Rolexes are great Ugandan street food - a chapati with an omlette rolled up inside (hence the name rolex). We also play games together as a house. We have had a few nights of playing cards, one game of ultimate frisbee, and 2 soccer matches. I don't mind sharing a room and a bathroom and a kitchen and common area with so many people because all the people are really fun to be around. But you can see why I have had a hard time finding time to blog with everything happening around me!

It's nice to know that I have met such great people while living here that in the event that anything bad happened, I know I would have a houseful of people that would be by my side the entire time. I know this because of an incident we had during our ultimate frisbee game. We were having a great time playing. The score was close and so we were all getting a little competitive. One of the girls on my team was going to catch a pass when a girl from the opposing team tried to block it. She ended up sliding into the girl from my team. The game immediately stopped and we all ran over to see my roommate lying on the ground in pain holding her leg with her ankle clearly dislocated and likely broken. Although the hospital is a great experience as a student, it is not a place I would choose to go to as a patient if I could help it. Everyone playing went on a mission - one called our international student coordinator to figure out what hospital to take our friend to, one went to get her money, ID, insurance information, one went to get transport to take her to the hospital, one got some pain medication that she had brought with her. The whole house came together to help one of our own. On the ride to the hospital, there were 4 of us in the van with her trying to get her leg still. Once at the hospital, 3 more of our housemates came to join us bringing more personal items for our injured friend and money in case we didn't have enough to cover the bill. It was really inspiring to see this international group of students who hadn't known each other for that long really rally together to support our friend in need. She ended up staying in the hospital overnight and then saw some Italian orthopedic surgeons in Kampala. The decision was made for her to fly home to have surgery. She has since had her surgery and is doing well at home. We all miss her and wish she was still here with us!

I have had three weekends in Uganda since I arrived and have traveled for two of those weekends. My first full weekend here, I went with a group of British students from Birmingham, Renee from the Netherlands, and Audrey - an American medical student I met on my Ob rotation to Jinja to go white water rafting down the Nile River. The source of the Nile is Lake Victoria and the start of the Nile is full of amazing rapids all the way up to class 6 (the highest class). We rafted 2 class 5 rapids and smaller ones as well. Apparently there used to be a lot more rapids and these rafting trips started closer to the source but in the past few years, a dam was built that has destroyed some of the rapids closer to the source. We were picked up on Satuday morning and drove to Jinja. At Nalubale headquarters, we were fed a breakfast of rolexes, bananas, and juice and were fitted for helmets and lifejackets. We then boarded a truck to head to our launch site. Once we arrived at the launch site, we were separated into two groups - one that was going to have the ultra super extreme rafting trip and another one that was slightly more tame. I, of course, wanting to get the full Ugandan experience immediately walked over to the ultra super extreme raft along with 4 of the 5 guys that were with us and 2 other girls. Our guide was from Zimbabwe and had been rafting for the past 15 years on various rivers throughout Africa and Europe. We entered the Nile at a wide calm spot to learn a few things about rafting before starting our trip down the rapids. Our leader taught us the different commands he would give for paddling forwards and backwards and how to keep in rhythm while paddling. He taught us how to "GET DOWN!" and hold on to the raft when we hit the major rapids. We practiced our short swimmer rescues and how to get ourselves back into the raft. We learned what to do in the event that we became long swimmers (too far from the raft to grab onto the rope on the side) and how to hang on to rescue kayaks properly. We were taught to fold up into a small ball when under the water to facilitate being shot back up to the surface more quickly and then once on the surface to back float with your head looking in the direction you were flowing with the current. Finally we practiced what to do when the raft flipped over. We were told to try our best to hang onto the paddle even when thrown off the raft and given some tips on swimming while holding the paddle. Feeling slightly more prepared, we started off.

The first rapid we hit was a grade 5 and it was a drop down a waterfall. Our leader told us that we really, really didn't want to flip on this rapid. We hit it just right and went over the falls landing with a big splash and paddled our way out of the falls. We watched as the second group went over. They didn't hit it quite as well as we had and ended up partially stuck under the falls and needed the safety boat to throw them a rope and help pull them out from the falls. We continued down the river and the next rapid we hit was a grade 3. We thought we were doing really well paddling through it and then we flipped. We were all a bit suspicious that our raft leader had something to do with our flip. This was confirmed after watching the video and seeing the photos from the rafting trip that indeed we were sabotaged. This set the precedence for the rest of the rafting trip. Except for the very first grade 5 (we had a second one later on in the trip called "The Bad Place") and one other rapid that was only a grade 3 but had some treacherous rocks that the current was directed towards, I was out of the raft on every other rapid...something like 5 or so rapids. Outside of the two where no one fell out, there was only one other rapid that the whole raft didn't turn over on although I was not one of the ones who managed to stay in the raft. It was a blast! I never once felt unsafe. The rescue kayakers were great at getting to you quickly when you became a long swimmer and brought you back to the raft. Even when I was under the rapid, I had a great time being tossed around by the Nile. I folded myself into a ball and got shot up to the surface relatively quickly although at The Bad Place, I was just sucked back under after getting a good breath of air. Our leader definitely lived up to the ultra super extreme rafting experience as he took us down the path of each rapid that would most likely wind up with our raft flipping and if that didn't do it, he flipped us himself. The final rapid called The Nile Special was great fun - I ended up out of the raft near the start and riding it the whole way down. I swam to our raft far downriver.

In between the rapids, we took our time in the slower moving water and swam in the Nile, reapplied sunscreen, and drank some water. We also had a lunch break midday with a delicious sandwich, chips and guacamole, and pineapple. That night we stayed at the Nile River Camp which was a great lodging along the banks of the Nile River. The best part about it was the rope swing that you could swing into the Nile from. That and the hot showers. After a good night of sleep, the next day we went into Jinja and to see the actual source of the Nile. We had heard/read that it wasn't all that impressive, but I thought it was still really cool to see where this famed river originates. The town of Jinja (the second largest in Uganda) was pretty sleepy on that Sunday afternoon but still very pleasant to walk around. After seeing the source and walking around Jinja, we returned to Nile River Camp and took the busy back to Kampala. It was a great first weekend in Uganda.

The following weekend, Renee (my roommate from the Netherlands who is here the entire time I am), Audrey (from Seattle - arrive the same time I did and is staying for 5 weeks) and I took the bus from Kampala to Sipi Falls in eastern Uganda near Mt. Elgon, the highest peak in Uganda and near the Kenyan border. We had heard that the falls were really beautiful and the weekend very relaxing and peaceful. We had a bit of an adventure to get there. We left the hospital early to try and get an early afternoon bus to Mbale but the buses were full until 5:30. The drive to Mbale takes at least 4 hours and sometimes as many as 6 hours and then from there, it is another hour by private hire to the town of Sipi Falls. While waiting for the bus, we had a nice lunch in Kampala City Center. The bus trip took about 5 hours and we arrived in Mbale at 10:30 at night. We had not arranged for any transportation to meet us in Mbale and along the route, the manager of the lodging we were planning to stay at kept calling me to see where we were on our journey. Thankfully, the people from the Mt. Elgon Flyer bus service in Mbale were able to help find us a private hire to take us to Sipi Falls. We finally arrived around 11:30 at the Crow's Nest - a place with supposedly a gorgeous view (which we couldn't see because it was dark) and a bit rustic. They use a generator that they only run for certain hours of the day so we had kerosene lanterns to light our way to our dorm room and for light as we got settled and ready for bed.

The following morning, we were not disappointed seeing the view from outside our dorm. We were on a hill overlooking a valley and Sipi Falls. It was breathtaking and so quiet and peaceful. We ordered our breakfast (it takes a while to get it after you've ordered) and got ready for the day. We arranged for a guide from the Crow's Nest to take us on the long hike through the village, farmlands, and hills to the three waterfalls. Seeing the rural way of life in Uganda was so nice. Most people farm and one of the major crops in this region is coffee. I had no idea that coffee beans on the tree are actually encased in a red shell and look a bit like berries. The hike, despite being at a relatively leisurely pace, still made all of us slightly out of breath due to the altitude. It was nice to take breaks and be able to take in the view from the tops of the hills we were climbing. About halfway through our long hike, it started to rain. Thankfully we all had rain jackets with us as the rain became progressively harder and everything not covered by the rain jacket was soaked. In many ways, this made the hike even more fun. The top waterfall was the smallest of the three but still very nice. There was a "swimming pool" at the base of it but because we were already pretty cold and it didn't look all that inviting, we decided not to get in. The second falls was probably my favorite. We started at the top of it then hiked down to the bottom. There were two parts of this set of falls - the main waterfall and an adjacent one called the "shower." I was glad I had my waterproof/shockproof/freezeproof camera with me to take with us as we stood underneath the shower and got some great pictures of the three of us. Finally we hiked to see Sipi Falls itself - a 99m high waterfall that drops down amongst a background of such lush greenery. It was serene.

After our hike back to the Crow's Nest, we were all glad to change into some dry clothing. We went up to the main lodge to read, relax, and hang out before our dinner (which we had ordered that morning) that we had planned for 6:30. Dinner was delicious and after that we played a card game that Renee taught us - a Dutch game called "Beste" (not sure of the spelling). Renee and I are both quite competitive and especially, I think, with each other when we play games. (It is a friendly, but serious competition between us - we both really like to win). A fourth person staying at the Crow's Nest asked to join in our game so the 4 of us played. To win the game, you have to win 5 rounds. Renee and I were neck and neck the entire evening while Audrey and our new friend were sitting with only having won about 1 round each. I ended up winning the game overall :) We went to bed that night relatively early because without electricity, there is not much to do.

Sunday morning, we got up and met our guide for our planned coffee tour. We went to the home of a local coffee producer and learned the art of making coffee. Starting from the red encased beans, we broke these open to expose the two pale coffee beans inside. These had to be placed in a large mortar and pestle and ground until the coating came off of these beans. Then this was emptied onto a plate and the beans separated from the coating by blowing gently on them. After this, the beans were placed in a pot and put over a fire for roasting. While constantly stirring, we waited to hear the crackle of the beans indicating that they were finished roasting. These were then emptied back onto the plate and we sampled our freshly roasted beans - delicious! The roasted beans went back into the mortar and pestle and were ground up manually in order that we could make coffee. After grinding the beans, the coffee grounds were placed in a pot of boiling water over the fire and boiled for several minutes. Then this was poured through a strainer into a flask for us to drink out of. It was probably the best cup of coffee I have ever had. The flavor was so rich and bold. Coffee lovers everywhere really should go through this process to have the freshest tasting coffee. Amazing.

We went back to the lodge and arrange for a private hire to take us back to Mbale so we could catch the bus back to Kampala. The ride home was much quicker than the ride there and we got back in the early evening ready to start another week at Mulago.

The third weekend (right after my last week on Ob), Renee and I spent in Kampala. A few of our housemates were leaving that weekend to go back home and since we had traveled the previous two weekends and were going to be here for a while still, we decided a quiet weekend was in order. On Friday night, I had been invited to a house party of the the Ob/Gyn resident from the UK that I had been working with on the wards. She told me that all my housemates were welcome to come as well. I wasn't sure what the house party would be like and I was nervous that it would be a total bust especially because I wasn't really sure where it was and it took a while to get a hold of my friend for better directions while we were on the road. We finally made it, and the house was full of people. It was probably the best house party I have ever been to - the house was very nice and they had hired a DJ as well as a rolex man (a rolex is a chapati with an omlette rolled up inside - a Ugandan street food favorite). All the beverages were also provided. We had a blast dancing and making new friends and didn't end up coming back home until the early hours of Saturday morning. Saturday morning, Nicole - one of my roommates returned from her rural rotation. We had a lazy Saturday sitting at the Makerere Guest House using the internet and just relaxing. On Sunday, Nicole, Renee, me, and Sarah (a new arrival to Edge House) went to Kabira Country Club to spend the afternoon at the pool. Although it is a little pricey, it is a great pool to swim in and lounge by and they have really great food. In addition to hanging out by the pool, Nicole and I decided to get hour-long massages (only $10!!). It was a good massage but definitely the most full body massage I have ever experienced. I don't know that I will have another while I am here, but the one time experience was very relaxing.

So that pretty much sums up the first three weeks and as I am writing this and have been in Uganda for 5 weeks, I have a lot more to catch up on in more recent blogs. I hope to write about my experience on the Surgical Casualty ward and my safari to Murchison Falls by the end of this weekend!

Location:Kampala, Jinja, and Sipi Falls

Sunday, April 29, 2012

The First Three Weeks - Ob/Gyn at Mulago Hospital

Olyotya! (Lugandan greeting). It's hard to believe I have already been in Uganda for three weeks. I just finished my last day of my Ob/Gyn rotation on Friday and will move on to the Casualty Ward (Emergency Medicine) next week. It has been an incredible experience so far and I am absolutely enjoying every day.

I spent the three weeks of my Ob rotation on the high risk labor and delivery ward. At the end of my time, I delivered 9 babies - most of them I did solo and learned how to repair second degree tears. The labor ward at Mulago Hospital has the most deliveries per capita in all of Africa. With the Ugandan fertility rate being 6.7, the hospital delivers on average 80-85 babies per day. The main labor ward of the high risk unit contains around 25 beds. On most days, all of these beds are filled and often there are mats laid out on the floor with another 3-10 laboring women lying on those as well. Most of the women end up delivering when they are on a bed, but on the busiest days, there are a few that end up delivering their babies on the floor. There is no privacy within this ward. Not even curtains or dividers to separate the beds. No one is allowed to come into the ward with the woman - not the father of the baby or family members or friends. It is overcrowded as it is and so no one is allowed inside except for the laboring mothers, a few midwives, a few nurses, the international students posted to the ward, and the doctors, interns, and residents during the rounds. The day typically starts at 8:30am with the morning report. It is really interesting as they report daily the events from the previous 24 hours. For the labor ward, they report how many deliveries, both vaginal and cesareans, complications from the deliveries (stillbirths, maternal deaths, multiple births, breech deliveries, etc.), and go over the pending cesarean cases. There is a lot of discussion that takes place after the report and it is really encouraging because the Ugandan Ob/Gyn doctors, midwives, and nurses are very proactive to try to identify major problems and discuss ways to resolve these problems. The maternal mortality rate is unfortunately high in Uganda and despite the lack of resources and inadequate staff, there is a strong motivation to find whatever way they can to try and reduce this using the resources and the staffing that they have.

Following the morning report, we head off to our respective ward rooms for rounds. On rounds in the main labor suite, there is a senior house officer (a resident), 1-3 junior house officers (interns), the international medical students, occasionally a consultant and occasionally Ugandan medical students. We go through every patient in the main labor suite - review their case, do an exam, and discuss the complications. The primary purpose of the ward rounds seems to be to make the prioritization of cases for cesarean section for the day. There are always more patients that need cesareans that will get them before they deliver vaginally so it is really important to prioritize the cases from the most urgent to the least urgent. This is difficult in and of itself, but unfortunately on a regular basis, there are patients that seem equally needy for cesarean. One day in particular, there were three women who had all had two previous cesarean sections (meaning that there chance of rupturing their uterus is unacceptably high). One was dilated to 7cm, one to 6cm but with a multiple pregnancy, and one only at 4cm but with signs of possible rupture occurring at that moment. When rounds are finished - often after a few hours and often interrupted by anywhere from 1-6 deliveries - the doctors all leave. Some go to admissions, some to the operating room to start on the list of cesareans, some to the pre-eclampsia/eclampsia ward, and some to the high dependency unit. After this, the only people left in the main labor suite to take care of the 25+ near-delivery mothers are 1-3 midwives and the international students. At times things are quite quiet but it seems that as soon as one delivers and that baby lets out its first cry, then several start to deliver. Some of the women yell (typically you hear cries of "Musawo!" which means doctor in Luganda) as they realize they are about to deliver while others are pretty quiet and I have often found myself turning around only to see a woman on her back with her legs flexed and the head of her baby starting to crown. I throw on my gloves, if I have time (as in the head is just at the introitus and retreats when the mother is not pushing), I will gather the supplies needed for the delivery - a syringe of 10 IU oxytocin, two elastic cuffs from gloves to use to tie off the umbilical cord, and a blade to cut the cord. If I really have time, then I will try to find the blanket that the woman brought to have her baby wiped down with and get the cotton ready. The women have to bring their own supplies for the deliveries - they are supposed to bring cotton to clean themselves with, two plastic sheets to lie on to try and keep the bed clean, bleach to wipe the bed down with after delivery, as well as sterile gloves for the person doing the delivery and for their vaginal exams prior to delivery.

I was a little terrified with the first baby I delivered in Uganda. The head was crowning and because another international medical student and I were standing at the bedside, the midwives assumed that we were fine and did not need them. Besides, there was a lot more work to be done elsewhere so if we were not in need of help, then they had a lot of other things to be doing. As the mother was pushing, I realized that head seemed to be too big to fit through the vaginal opening. We don't routinely cut episiotomies in the US, but it seemed in this case that one was needed. I had never cut an episiotomy before in my life and did not feel comfortable experimenting without supervision on a Ugandan woman and had to ask the midwife twice to come over and cut it for me before she finally came over and did it. As I delivered the head, I felt for a nuchal cord which there was one wrapped twice around the baby's neck. I couldn't get it reduced and so stuck my fingers between the cord and the neck to try to protect the baby from suffocating and finished the delivery. Everything turned out fine - the baby was healthy and had a good cry. The mother was so grateful for my help in delivering her baby and kept telling me "thank you, thank you" over and over again. It was a great feeling. After that first delivery turned out well, I no longer felt terrified of the imminently delivering mother. In addition to delivering several babies on my own, I also helped some of the other international students deliver babies as well. Several of them had never delivered a baby before and a few had not even had Ob/Gyn at home yet. It was fun to do some teaching and get some incredible practical experience as well.

Unfortunately not all the deliveries turned out as well as my first one. Everyday I saw at least one stillbirth and participated in three of those deliveries myself - one that I did solo. Sometimes the mothers seem to know when they are going to delivery a stillborn and other times, it comes as a surprise. There are also times when the baby comes out not breathing and due to a lack of a well equipped NICU, many of these babies don't make it despite our best resuscitative efforts with the resources we have. The worst stillbirth experience for me was with a mother who knew she was giving birth to a stillborn. The baby was in a breech position and when I walked onto the ward that morning, I saw the woman lying on the bed with the baby half out. She had stopped having contractions and had been stuck like that for I'm not sure how long. I alerted the doctors doing rounds to her predicament and was told to start an IV with 10 IU of oxytocin to try and get her to contract. I did this and as I was standing there, she asked me if she was going to die. I told her no, that she was going to be fine. She asked me if I would stay by her and not leave and I of course said yes, that I would stay with her until she delivered. After about 30 minutes of the IVF running and still no contractions, I again alerted the doctors who told me to add another 10 IU to her IV. They said that when she had her next contraction, I should deliver her baby. I have never done a breech delivery in my life and even though the baby wasn't alive, I certainly did not feel comfortable tackling this one on my own. Again, no one would come to help. The midwives told me to leave her be and she would deliver on her own, but I had promised her that I would not leave her so that was not an option. When the mother seemed to have a contraction, I instructed her to try to push. The baby was completely stuck. At this point it had been about an hour since I had started that IV and beyond this one weak contraction, the mother was not having any. I again asked the midwives to help. They told me to just wait. I asked the doctors to help and they said that they would come back to her when they finished their rounds. I kept pleading and finally a visiting resident from Canada came over and assessed the situation. She agreed with me that this baby was not going to deliver on its own and was able to recruit the Ugandan consultant and intern to come and help with the delivery. Turns out I was right. In order to deliver this baby, the consultant had to dislocate both shoulders, broke one arm and finally got the arms delivered (which had been up above the baby's head). After delivering the arms, the consultant realized that the baby seemed to have hydrocephalus and so the head was way to big to deliver. So, they had to manually drain CSF from the baby's skull in order to shrink the head to get the baby out. Nearly 2.5 hours after I first saw this woman, she had finally delivered her stillborn. Thankfully she seemed stable after this traumatic labor and delivery experience. In the US, breech is an indication for cesarean but here, there is not enough OR space to section all the breech babies so many of them end up delivering vaginally. Of the 4 breech deliveries that I saw and helped with, only one lived through the delivery.

The other really traumatic delivery I helped with was for a woman with severe eclampsia who had major mental status changes because of her eclampsia. She was agitated, anxious, and almost seemed to be in a psychotic state. Her baby was stuck and because there was no space for her in the OR, the decision was made to try a vacuum delivery. A third year resident from the UK that I had been working with for two of the weeks I was on the ward took charge of this delivery. This resident was the best part of my Ob rotation - she was an incredible teacher and provided the perfect amount of supervision and autonomy. She really cared about each and every one of the patients and we teamed up on many deliveries which I think made the whole process go much more efficiently and better overall for the mothers we delivered. Anyway, this particular mother due to her eclampsia and her mental state was aggressively uncooperative. We sedated her with diazepam and it still took four of us holding her down to be able to deliver her baby by vacuum. Thankfully, the baby came out alive but needed immediate resuscitation and so the resident and two of the other international students left to work on that. The Ugandan midwife and doctor who had also been helping disappeared and so I stayed with the mother who was lying in a pool of blood from the episiotomy that had to be cut to deliver her by vacuum. She was continuing to bleed and I was concerned about her stability since she was bleeding and had been given sedation. I watched her respiratory rate and kept checking her pulse and watching her bleeding. One of the midwives stopped by and looked at the patient, shook her head saying "that was not the right way to cut an episiotomy - what a mess" and walked away. The UK resident returned and between her and the three of us international students, we tried to hold her down to repair her episiotomy. The mother was still fighting us despite her sedation and we asked the midwife to come and help hold her down. It seemed like all she really had to contribute was criticism - for the episiotomy and the "slowness" of the repair and for the fact that I was leaning over the patient, trying to hold her down and subsequently was getting blood on my clothes. I said that I could wash the blood out of my clothes later and the resident told her that she should show her how to do a fast repair. The whole scene just felt wrong - four people holding down this poor woman while someone tried to suture her and stop the bleeding. It was a sloppy job, but it seemed to work to stop the bleeding. At the morning meeting the next day, I found out that the patient and the baby were both stable and the mother was in a better mental state than the previous day.

Every day was a complete adventure on the labor ward and if I wrote all the stories I had to tell about my experiences, it would be a short novel. It was incredibly hard and difficult but also equally rewarding. I felt like I was learning so much and at the same time was able to give back and help others. Even though at times it seemed like people didn't care or moved too slowly when you needed something NOW, they really do an amazing job with the resources that they have and for every person that seems to not care when something terrible happens, there are at least two that really do care. I was also so inspired by the motivation of the staff to identify problems and try to brainstorm ways to fix them to decrease their maternal and neonatal morbidity and mortality rates. I am sad that my time on Ob is over, but I am excited to start something new - Emergency Medicine!

Location:Kampala, Uganda

Tuesday, April 10, 2012

The Beginning of the End - Arriving in Kampala

So I may get back to my India blogging, but then again, now that I am in Uganda, I may just forget writing about the rest of India and just move on to my last and final location of my world wide medical student tour.

I flew out of Minneapolis on Friday, April 6 at about 3 in the afternoon. My mom and sister brought me to the airport after we stopped and had lunch with my brother in St. Paul. When I got to the airport, my one checked bag was 6lbs overweight. Even though I was given 2 free check bags each 50lbs which means I should have gotten 100lbs of weight to bring, Delta was going to charge me $90 for my 6lbs overweight bag. I refused to pay that and I didn't have another bag to check, so I unloaded my shampoo and conditioner and some other liquid things that I had planned to bring and got my bag down to 50lbs. Going through security was a breeze and I sat at my gate for a little over an hour before we boarded the plane for Amsterdam. The flight to Amsterdam was entirely uneventful as all good flights are. I ended up sitting next to a girl around my age who works for the CDC and was also headed to Uganda for 4 weeks to do a project here. The slightly less than 8 hour flight went by relatively quickly and we made it to Amsterdam. I didn't sleep at all on the flight and was quite tired by the time we arrived in Amsterdam. The airport is not very conducive for sleeping, but as I was tired, I still managed to sleep for an hour on the tiled floor.
I boarded the plane to Kampala with a stop over in Kigali, Rwanda and the flight was relatively empty so I ended up with a row to myself. The guy sitting in the row next to me was a really nice guy from Texas who was going to Uganda for the second time to do some military training for the Ugandan soldiers. He has been to Africa several times and has loved all of his trips. It was great to get a bit of insight prior to my arrival especially with regard to trips to take on the weekends! This flight was also uneventful and I made it to Kigali and then to Kampala without problem. On this flight I only slept for about an hour as well.

Once I arrived in Entebbe (about 35km south of Kampala and the location of Uganda's international airport), I was quickly able to retrieve my bag and get my Ugandan visa ($50). The whole thing went so smoothly and as I walked out of the baggage claim area, I saw a man with a sign with my name on it who I presumed was the person sent from the school to pick me up. He and his wife welcomed me warmly to Uganda and we got into the Makerere University van. It was unfortunate that it was night (10:30 or so) when I arrived so that I couldn't see the scenery on my ride from Entebbe to Kampala. But I was quite tired and ended up falling asleep on the ride to Kampala. I was brought to my housing - the Edge House - on the Makerere campus and was greeted again very warmly by Lucy and Nasser who run the house. None of my housemates were around as the Easter weekend provided for a long holiday weekend so everyone was gone. I was okay with that as I was really tired and after unloading my things, I fell asleep and slept until nearly 11am on Sunday morning.
Sunday was a very relaxing day. I wrote my blog about Goa, did some reading, took a nap on the outside porch, went shopping for some groceries and the toiletry items I was forced to leave behind in Minneapolis, and enjoyed being in my new home. One of my housemates, Cecilia from Sweden, returned from her weekend trip with her boyfriend and it was really nice to meet the both of them. Cecilia has already been here for 4 weeks and will be here for another 2 months so we will get to know each other quite well I think by the time she leaves at the beginning of June. Sunday night Nasser took me to get a SIM card for my phone and also get some data so I can connect my phone to the internet. It was so easy - we just asked for a SIM card and got it. Then I bought the airtime and it worked. So easy.
Monday morning I slept in quite late again and was woken up by Lucy when a Makerere medical student arrived to take me on my orientation tour. I had to quickly get ready and then headed for my tour. Along with me were two other medical students from UCLA who had also just arrived. We first met with the international student coordinator, Susan who was very friendly. Then we took a tour of Mulago Hospital where we will do our clinical rotations. Finally, our orientation ended with a tour of Kampala itself - the city center and downtown. It was really cool to see some more of the city and kind of get some idea of the layout. Kampala is a much cleaner city than Bangalore and the sidewalks are actually walkable. It's definitely not as crowded nor is the traffic anywhere near the level it was in Bangalore. So far, I am really loving it here. The only bad thing that happened on our tour was that near the taxi park in downtown, a man tried to steal the necklace off of one of the other medical student's neck. He did not succeed and she was okay, but it definitely raised all of our heart rates a bit and made us keep a little tighter hold on our bags.
When I returned to Edge House late that afternoon, I met the rest of my housemates and my roommates. The group is fairly international although the majority of students are either from the US or England. We have one from Sweden and one from Holland. It was one of the American's birthday on Monday so 12 of us that are living in the house went out for dinner together to celebrate. Everyone has been so friendly and welcoming and I feel like I am at home already. I am so happy to be hear and think that this will for sure be the overall best of my experiences yet.
I am writing this on Tuesday after my first official day at Mulago but I will save the going-on of today for the end of the week when I can recap my first week of Ob/Gyn at Mulago.

Location:Kampala, Uganda

Sunday, April 8, 2012

Goa (Feb. 24-28)

The weekend before I started Ob/Gyn, Kim and I talked about taking a trip to Goa. She had been to Palolem Beach with Michael, Carina, and Carina's boyfriend Noti the weekend of my birthday but had heard about a beach party happening at Morjim Beach in north Goa that she really wanted to go to. I just wanted to go to Goa so we decided to try and make that happen the following weekend. During the week, our group going to Goa grew - it started out just Kim and me and then Carina, Sonja, and Julia all decided to join us as well. The problem was that we tried to buy our bus tickets very last minute. We went to the travel agency on Wednesday afternoon to buy bus tickets for the weekend. We had decided to go for a long weekend and leave on Thursday night. We had a horrible time trying to get bus tickets. We spent around 2 hours at the travel agency with no luck. There were tickets showing up on the website, but for some reason we were unable to book them. Then we each tried to buy tickets online on our own computers but were again unable to book bus tickets. This was the only time during my time in Bangalore that the bus ticket websites (we tried several) would not accept my American credit card. Just when we thought there was no way we were going to be able to make it Goa, our magic friend Mahesh came through for us. He got on the phone with someone and suddenly we had bus tickets for all of us on a sleeper bus leaving Thursday night for Goa. Unfortunately, we could not get bus tickets to return on Monday morning so we ended up having to change our return to Tuesday morning.

Thursday night we headed to the bus pickup point and made it on our bus with our handwritten paper tickets. We were not confident these tickets were valid since none of us had had handwritten tickets before this. Thankfully, they worked without a problem and we boarded our bus to Goa. The difficult thing about being on a sleeper bus with 5 people is that often the beds are shared between two people. Since Julia was the last person to decide to join us on the trip, she ended up sharing a bed with a stranger. This actually worked out to our advantage. The guy Josi was an ex-pat living in Morjim Beach. He knew a guy with a car that would be able to pick us all up from our bus drop off point and bring us the rest of the way to Morjim Beach (about an hour away) for a very cheap price - 700Rs for all 6 of us (about $2 per person). He also knew the owners of a group of beach huts and was able to get us a great deal on our accommodation as well. We paid 450Rs per room per night which split between two people was less than $5 per night. They were clean huts with a great location. There was a common shower and toilet that everyone used, but for $5 per night, none of us could complain.

After arriving at our huts, rearranging our bags, showering, and changing into our beach wear, the 5 of us headed out for breakfast on the beach. The place we went to - Fish and Feni - ended up being our breakfast place for the duration of our stay. The food was delicious, the service great, and the prices very, very reasonable. The fresh fruit and the fresh fruit juices were amazing as were the omlettes. After breakfast, we headed down to the beach and began our weekend of relaxation - napping on the beach, reading, swimming in the ocean, and of course eating. Late afternoon on Friday we decided to head over to this party that Kim had found and have lunch in that area before checking it out. We went to this Italian place on the beach. The food was good but it took 2 hours for us to get it. To make up for their incredibly slow service, they brought us two pitchers of sangria. Even though we didn't have anywhere we needed to be, we were all starving and a little frustrated at having to wait so long for our food. We finally did eat and then headed to the party next door.

I have never been to anything like this party. The music was loud and the place was packed with people - mostly Europeans - who were all dancing, sometimes very crazily, to the beat of the music. I think a lot of the people were on some kind of drug but it was great for people watching. Julia left to meet up with Josi and Carina and Sonja left soon after because of the crowdedness of the place. Kim wanted to stay and although I am sure she would have been fine on her own, I didn't really want to leave her by herself so I stayed as well. After a couple hours of dancing and a ton of sweating, we walked out of the party to get some fresh air. It was a little after 8pm and the sun had set. We still had our swimsuits on and so to cool off, we decided to jump into the ocean. We set our stuff a little ways down the beach - our clothes, flip flops and put our wallets, phones, and my camera buried within the clothes. We jumped into the ocean and played around in the surf for no more than 10 minutes and when we got out and went back to our stuff, it was gone. After searching up and down the beach area and asking anyone nearby if they had seen our stuff, we headed back to our huts in our bikinis to put on more clothes and get a flashlight to look for our things. We were sure it was stolen, but as the clothes really had no value, we were hoping to at least find those thrown somewhere. When we returned to the huts we had an additional problem. I had used my own personal padlock instead of the one provided to us by the hut to lock everything up and the key had been inside my wallet and the spare key in Kim's wallet. We had to have the staff break into our room my removing the bolt on the door (which definitely needed replacing anyway) and replacing it. We got dressed, grabbed our flashlights and as we were heading back down the beach to the party, we ran into Carina and Sonja. We told them what happened and both tried calling our cell phones from Carina's phone. They had both been turned off. We did not find anything when we returned to the party to search for our stuff. We told the bartender at the party about our stolen stuff and asked if anyone turned anything in, if he would let us know. We walked back to our hut and decided to call it a night. Thankfully the flip flops were cheap and I had other sandals, the sarong I had on I bought in India which was no great loss, I didn't have any ID or credit cards in my wallet although I did have all the cash that I brought with me to Goa in that wallet (stupid, I know...), the camera was several years old and actually the back-up camera that I brought and only had pictures from that night on it, and the phone was cheap. The bad thing about losing the phone is that getting a SIM card in India was such a pain and now I would have to go and get another one.

Saturday morning I woke up early and couldn't get back to sleep. I decided to go for a run along the beach to burn off some of my frustrations of getting my stuff stolen and to also look in the daylight to see if any of our things of no value had been ditched. I ran back to the location of the party and did find both of our pairs of flip flops but nothing else. It was a beautiful morning so I decided to bring the shoes back to our hut and continue my run along the beach. On my way back to the hut, a young-looking Indian man in a white running outfit whom I had seen on my run to the party beach ran up to me and started running next to me. He asked me what I was doing and I said "running." He asked if he could join me and I said "No. I want to run alone." Then he asked where I was staying and I responded vaguely "On the beach." He then asked if he could go to the place I was staying with me. And again, more forcefully I said "No." As if somehow he thought I was not getting his intention, he then reached over and grabbed my crotch. Completely startled, I stopped pushed his hand away and yelled "Don't do that!" Thankfully at that point he turned and ran away. I continued running toward my hut and before I turned in, I checked to make sure he was not around before going in. I brought our sandals back and told Kim what had happened. I still wanted to continue running as now I had even more frustration to burn off and so Kim got dressed and went with me. After my second run with Kim, we went back to the huts and saw Carina. Carina had wanted to go for a run as well so I went on a third run with her. After all of my runs, I went back to the hut, rinsed off, changed into my beach stuff and went to the beach. Julia wasn't feeling well that morning and so didn't join us at our breakfast place for breakfast.

The rest of the weekend was much improved from the first 24 hours. I finally had a chance to relax and enjoy the weekend with great friends. We laid on the beach, swam in the ocean, ate good food, read (I finally finished the book Curry: A Tale of Cooks and Conquerors and read a great book that I highly recommend especially if traveling to India called The White Tiger), slept, and had great conversations. I'm so glad that I was there with such great friends since the weekend would have been a miserable disaster if all that had happened and I had been alone. I am very thankful that nothing worse happened with that guy on the beach and that I had good friends to help me out and make sure the rest of my trip was enjoyable. Monday night came all too quickly and soon we found ourselves back on a sleeper bus and heading back to Bangalore.

Location:Morjim Beach, Goa, India